1 Number of employees who recelved wages, tips, or other compensation for the pay period including: Mar. 12 (Quarter 1) 1 2 Wages, tips, and other compensation 2 3 Federal income tax withheld from wages, tips, and other compensation 3 4 If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6. Column 1 5a Taxable social security wages Sa (i) Qualified sick leave wages 5a (ii) Qualified family leave wages 5b Taxable social security tips 5c Taxable Medicare wages \& tips 5d Taxable wages \& tips subject to Additional Medicare Tax withholding Column 2 0.124= 0.062= 0.062= 0.124= 0.029= 0.009= 5e Total social security and Medicare taxes. Mdd Column 2 from lines 5a, 5a(1), 5a(ii), 5b,5c, and 5d 5f Section 3121(q) Notice and Demand-Tax due on unreported tips (see instructions) 6 Total taxes before adjustments. Add lines 3, 5e, and 5f 7 Current quarter's adjustment for fractions of cents 8 Current quarter's adjustment for sick pay 9 Current quarter's adjustments for tips and group-term life insurance 10 Total taxes after adjustments. Combine ines 6 throwh 9 Se 5f 11. Qualified small business payroll tax credit for increasing research activities. Attach form 8974 6 7 8 9 10 11 a Previous Nert Name (not your trade name) KAREN KLUSTER: Employer identification number (EIN) 000005874 Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank. 17 If your business has closed or you stopped paying wages enter the final date you paid wages ; also attach a statement to your return. See instructions. 18 If you're a seasonal employer and you don't have to file a return for every quarter of the year D. Check here. 19 Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021 19 20 Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021 20 21 Reserved for future use 21 22 Reserved for future use 22 23 Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021 23 24 Qualified health plan expenses allocable to qualified sick leave wages reported on line 23 24 25 Amounts under certain collectively bargained agreements allocable to qualified sick leave wages reported on line 23 25 26 Qualified family leave wages for leave taken after March 31, 2021, and before october 1, 2021 26 27 Qualified health plan expenses allocable to qualified family leave wages reported on line 26 27 28 Amounts under certain collectively bargained agreements allocable to qualified family leave wages reported on line 26 28 Part 4t May we speak with your third-party designee? Check one: a. Line 12 on this return is less than $2,500 or line 12 on the return for the prior quarter was less than $2,500, and you didn't incur a $100,000 next-day deposit obligation during the current quarter. If line 12 for the prior quarter was less than $2,500 biat line 12 on this return is $100,000 or more, you must provide a record of your federal tax liabiuty, If you're a monthly schedule depositor, complete the deposit schedule below; if you're a semiweekly schedule depositoe, attach 5cheduleB (Form 941 ). Go to Part 3. b. You were a monthly schedule depositor for the entire quarter. Finter your tax llability for each month and total liability for the quarter, then 90 to Part 3. Taxllabilityt Month 1 Month 2 Menth 3 Total liability for quarter Total must equal line 12 . c. You were a semiweekly schedule depositor for any part of this quarter, Complete 5chedule 8 (Form 941 ). Report of Tox Liability for Semiweekly Schedule Deposters, and attach it to form 941 fin th Part a eBook Show Mo How 11b Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021 11b 11c Reserved for future use 11c You MUST complete all three pages of Form 941 and SIGN it. For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 170012 . Form 941 (Rev. 3-202 Name (not your trade name) KAREN KLUSTER Employer identification number (EIN) 000005874 Part 1: Answer these questions for this quarter. (continued) 11d Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021 11d 11e Nonrefundable portion of COBRA premium assistance credit (see instructions for applicable quarter) 11e 11f Number of individuals provided COBRA premium assistance 12 Total taxes after adjustments and nonrefundable credits. Subtract line 11g from line 10 12 13a Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941X,941X(PR),944X, or 944X (SP) filed in the current quarter 13a. 13b Reserved for future use 13b 13c Refundable portion of credit for qualified sick and family leave wages for leave taken before April 1 , 2021 13c 13d Reserved for future use 13d Using form 941 below, prepare the return on the basis of the information shewn above. Note: tines Sa and Sic of form 941, tax on total tavable wages, ore computed by muliplyng by the combined tax rate for both entolover and employee, Small differences Sue to rounding may occur between thid total and the total taxes withheld from emplorees each pay period and the amount of the employer's taxes cakulated each pay period. This ddference is reported on line 7 as a deduction or an addition as Wractions of Cents, Use minus sign to Indicate a deduction, If line 7 is xero, for orading purposes oniy, enter a zero. Assume that compony deposits taxes on monthily basis. Hint: Line 7 instructions. Fill in Form 941 through line 6, and then fill in part 2 , Kine 16 or Schedule 0 . Take that inflormation and fis in line 10 . Lines 6 and 10 must equal. If the amounts are not the same, correct by entering amount to make equal on line 7 . Line 7 differences are caused by how calculations are mode on form 941 and the amounts witheld from employee's earning pius the emplover's payroll tax amounts each pay period. vorm 941 for 20--: Employer's QUARTERLY Federal TaX Return (Weve Mards 2022) ans Na. 15459025 1 Number of employees who recelved wages, tips, or other compensation for the pay period including: Mar. 12 (Quarter 1) 1 2 Wages, tips, and other compensation 2 3 Federal income tax withheld from wages, tips, and other compensation 3 4 If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6. Column 1 5a Taxable social security wages Sa (i) Qualified sick leave wages 5a (ii) Qualified family leave wages 5b Taxable social security tips 5c Taxable Medicare wages \& tips 5d Taxable wages \& tips subject to Additional Medicare Tax withholding Column 2 0.124= 0.062= 0.062= 0.124= 0.029= 0.009= 5e Total social security and Medicare taxes. Mdd Column 2 from lines 5a, 5a(1), 5a(ii), 5b,5c, and 5d 5f Section 3121(q) Notice and Demand-Tax due on unreported tips (see instructions) 6 Total taxes before adjustments. Add lines 3, 5e, and 5f 7 Current quarter's adjustment for fractions of cents 8 Current quarter's adjustment for sick pay 9 Current quarter's adjustments for tips and group-term life insurance 10 Total taxes after adjustments. Combine ines 6 throwh 9 Se 5f 11. Qualified small business payroll tax credit for increasing research activities. Attach form 8974 6 7 8 9 10 11 a Previous Nert Name (not your trade name) KAREN KLUSTER: Employer identification number (EIN) 000005874 Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank. 17 If your business has closed or you stopped paying wages enter the final date you paid wages ; also attach a statement to your return. See instructions. 18 If you're a seasonal employer and you don't have to file a return for every quarter of the year D. Check here. 19 Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021 19 20 Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021 20 21 Reserved for future use 21 22 Reserved for future use 22 23 Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021 23 24 Qualified health plan expenses allocable to qualified sick leave wages reported on line 23 24 25 Amounts under certain collectively bargained agreements allocable to qualified sick leave wages reported on line 23 25 26 Qualified family leave wages for leave taken after March 31, 2021, and before october 1, 2021 26 27 Qualified health plan expenses allocable to qualified family leave wages reported on line 26 27 28 Amounts under certain collectively bargained agreements allocable to qualified family leave wages reported on line 26 28 Part 4t May we speak with your third-party designee? Check one: a. Line 12 on this return is less than $2,500 or line 12 on the return for the prior quarter was less than $2,500, and you didn't incur a $100,000 next-day deposit obligation during the current quarter. If line 12 for the prior quarter was less than $2,500 biat line 12 on this return is $100,000 or more, you must provide a record of your federal tax liabiuty, If you're a monthly schedule depositor, complete the deposit schedule below; if you're a semiweekly schedule depositoe, attach 5cheduleB (Form 941 ). Go to Part 3. b. You were a monthly schedule depositor for the entire quarter. Finter your tax llability for each month and total liability for the quarter, then 90 to Part 3. Taxllabilityt Month 1 Month 2 Menth 3 Total liability for quarter Total must equal line 12 . c. You were a semiweekly schedule depositor for any part of this quarter, Complete 5chedule 8 (Form 941 ). Report of Tox Liability for Semiweekly Schedule Deposters, and attach it to form 941 fin th Part a eBook Show Mo How 11b Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021 11b 11c Reserved for future use 11c You MUST complete all three pages of Form 941 and SIGN it. For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 170012 . Form 941 (Rev. 3-202 Name (not your trade name) KAREN KLUSTER Employer identification number (EIN) 000005874 Part 1: Answer these questions for this quarter. (continued) 11d Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021 11d 11e Nonrefundable portion of COBRA premium assistance credit (see instructions for applicable quarter) 11e 11f Number of individuals provided COBRA premium assistance 12 Total taxes after adjustments and nonrefundable credits. Subtract line 11g from line 10 12 13a Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941X,941X(PR),944X, or 944X (SP) filed in the current quarter 13a. 13b Reserved for future use 13b 13c Refundable portion of credit for qualified sick and family leave wages for leave taken before April 1 , 2021 13c 13d Reserved for future use 13d Using form 941 below, prepare the return on the basis of the information shewn above. Note: tines Sa and Sic of form 941, tax on total tavable wages, ore computed by muliplyng by the combined tax rate for both entolover and employee, Small differences Sue to rounding may occur between thid total and the total taxes withheld from emplorees each pay period and the amount of the employer's taxes cakulated each pay period. This ddference is reported on line 7 as a deduction or an addition as Wractions of Cents, Use minus sign to Indicate a deduction, If line 7 is xero, for orading purposes oniy, enter a zero. Assume that compony deposits taxes on monthily basis. Hint: Line 7 instructions. Fill in Form 941 through line 6, and then fill in part 2 , Kine 16 or Schedule 0 . Take that inflormation and fis in line 10 . Lines 6 and 10 must equal. If the amounts are not the same, correct by entering amount to make equal on line 7 . Line 7 differences are caused by how calculations are mode on form 941 and the amounts witheld from employee's earning pius the emplover's payroll tax amounts each pay period. vorm 941 for 20--: Employer's QUARTERLY Federal TaX Return (Weve Mards 2022) ans Na. 15459025